Concept for Nursing Theories course (End-of-life care) - Term Paper Example

Introduction I chose the concepts of end-of-life care and end of life, because the population of America is increasingly becoming more composed of patients ages 60 and beyond, and so end-of-life care has become an urgent issue for the nursing profession. For the next thirty years, the number of older Americans will swell. By 2030, the baby boomers will already turn 85 or older (Lippincott Williams & Wilkins, 2007, p.2). Clearly, end-of-life care will be an increasingly pressing concern for millions of Americans for the next decades, as well as their families and the health care system. One of the main concerns of end-of-life care is the provision of quality care for end-of-life patients, which can be difficult to define for all involved stakeholders. For the society and many health care professionals, death is a sign of failure, and they are hesitant to allow people to naturally die from their illnesses. End-of-life care is critical, because nurses have to balance conflicting goals, such as helping patients and their families deal with the process of “letting go” and helping patients experience quality of life, while still living. End-of-life care will also contradict the goal of some patients and their families to extend life, even when illnesses are already terminal. This paper explores the concepts of end of life and end-of-life care and its definitions. It will determine the criteria for the concept of end-of-life, how it is addressed in literature, tools for measuring the concept, antecedents and consequences, and it will also provide three cases for end of life care. Literature Review End of Life Concept Karlsson and Berggren (2011) define end of life, as the phase of patient life, where “curative care is no longer possible” and survival time is considered “short” (p.374). Epstein (2010) is concerned of end of life’s implications on the quality of caring provided to dying patients. For him, the health care staff should be concerned of end of life’s implications to “dissatisfaction, conflict, and moral distress” (p.577). It is inferred that he defines “end of life” as a critical phase of care delivery, as the end of care looms. Reinke et al. (2010) agree with Epstein (2010) and affirm the necessity and urgency of the issue of quality care when end of life is concerned. Reinke et al. (2010) define end of life as the care response to the physical, emotional, social, and spiritual needs and concerns of dying people (p.753). End-of-Life Care Concept Lippincott Williams and Wilkins (2007) define end-of-life care in terms of palliative care, where the latter aims to prevent and relieve suffering and to advance the patient’s comfort and quality of life (p.3). There is no goal of hastening or delaying the patient’s death, and instead, stakeholders accept death as part of the natural cycle of human life (p.3). Poor (2001) also defines end-of-life care as a concept of palliative care, where it refers to the “comprehensive care of patients with a terminal illness who are nearing the end of life” (p.6). The World Health Organization (WHO) provides a more detailed definition of palliative care: “the active total care of patients whose disease is not responsive to curative treatment” (as cited in Poor, 2001, p.6). Some of the important goals of palliative care are to control pain and to respond to the psychological, social, and spiritual needs of the patient (Poor, 2001, p.6). The WHO provides the following characteristics of palliative care: 1) Life and death are normal processes; 2) Death is not delayed or encouraged; 3) Pain control and control of other upsetting symptoms are important; 4) The spiritual and psychological components of care are included in the care plan; 5) There is a support system for patients to live a quality and active life; 6) and there is also support system for the family of the dying patient, so that the former can cope with the upcoming realities of death (as cited in Poor, 2001, p.6). End-of-life care promotes holistic care that responds to the body, mind, and spirit of the patients (Poor, 2001, p.6). Brant stresses that through holistic care, one part of the body, mind, or spirit cannot be healed without the other (as cited in Poor, 2001, p.6). Another article conceptualizes end-of-life care as facilitating the process toward a “good death.” The Institute of Medicine (IOM) says that a good death is one that is absent of “avoidable distress and suffering, in general accord with one’s wishes, and is consistent with clinical and cultural standards” (Reinke et al., 2010, p.753). Epstein (2010) understands the difficulties of defining end-of-life care, especially when it requires an interdisciplinary approach. He laments that end of life care shows some conflict between nurses and doctors, because they function as “isolated silos” (p.578). Epstein (2010) defines end-of-life care as a “cumulative experience,” which requires coordination in making decisions, relieving pain and other symptoms, family support, and care sustainability (p.578). He argues that nurses and physicians must coordinate in providing sustained care along the “illness trajectory” (p.578). Gjerberg, Førde, and Bjørndal (2011) highlight the value of communication with the relatives of the patient, as elemental to quality of end-of-life care. It is important that the decision-making is transparent and people feel accountable for the outcomes of their decisions (p.43). Based on these definitions, I understand end-of-life care as the care for patients who are nearing their end of life and who do not want their deaths to be speeded or delayed. They can include do-not-resuscitate orders from patients with terminal illnesses, but they can receive symptom relief, so that they can experience an active or more comfortable life until the end of life. End-of-life care follows a holistic view of care, where health care professionals attend to the diverse psychological, social, practical, and spiritual needs and concerns of the patients. It consists of an integrated support system that responds to both patients and their families alike; so that they can all cope with the natural course of death and become prepared for the eventual death of their sick family members. Finally, it must have a transparent and accountable decision-making process, where all stakeholders are openly involved in discussing alternatives and outcomes (Gjerberg, Førde, & Bjørndal, 2011, p.43). Criteria for the Concepts End of care’s criteria is related to end-of-life care, since the former concerns end-of-life stages of human life and the role that the health care profession plays for patients in this category. Based on the review of literature, the criteria for end-of-life care are: 1) Acknowledgement of the natural cycle of life and death (Poor, 2001, p.6). 2) Provision of symptom relief (Epstein, 2010, p.578). 3) A holistic approach to planning and executing care, through the incorporation of psychological, social, practical, and spiritual aspects of patient care in planning for end-of-life care (Jeong, Higgins, & McMillan, 2010, p.390). 4) Interdisciplinary decision-making framework (Epstein, 2010, p.578). 5) Provision of support system to help the family cope during the patient’s illness and their own bereavement (WHO as cited in Poor, 2001, p.6). 6) Transparency and accountability of the decision-making process (Gjerberg, Førde, & Bjørndal, 2011, p.43). How Concepts are Addressed in Literature End of life itself is not a concept extensively studied in literature, except as related to end-of-life care. It seems that in the health care setting, end of life is critical, because the quality of end-of-life care has become an increasingly pressing concern for the population that is getting older (Gjerberg, Førde, & Bjørndal, 2011, p.43). The concept of end-of-life care is addressed in literature in a documented manner, where different stakeholders are interviewed about their perceptions, definitions, and participation in end-of-life care planning. Karlsson and Berggren (2011) define quality end-of-life care as something decided by the patient, thereby focusing on the autonomy of the patient and the decision to die with “dignity.” They focus on dignified ways of dying in the patient’s own home, where feelings of “security, presence, belongingness and receptivity” can be felt (p.375). Gjerberg, Førde, and Bjørndal (2011) underscore the significance of communication with the relatives of the patient, as elemental to quality of end-of-life care. It is important that the decision-making is transparent and people feel responsible for the outcomes of their decisions (p.43). Other studies validate the concept of end-of-life care through the issues identified by the stakeholders. Reinke et al. (2010) aim to determine the nurses’ perspectives on nursing skills that are noteworthy, yet “under-utilized” in end-of-life care. These end-of-life care skills composed of communication skills, symptom management competencies, specifically relating to anxiety and depression, and issues connected to patient-centered care systems (Reinke et al., 2010). Epstein (2010) investigates the ethical duties of nurses and physicians in neonatal end-of-life care. They are obligated to communicate honestly and ethically with the parents and consider the withdrawal of treatment (Epstein, 2010, p.578). Nurses and physicians believed that they have obligations in different end-of-life care categories, although nurse obligations focused on the end-of-life care, while physician obligations emphasized decision-making options (Epstein, 2010). The findings show that, although the final goal is regular to both disciplines, the courses identified to attain that goal are often dissimilar (Epstein, 2010). Tools for Measuring the Concept End of life is measured according to the severity of illness and expectation of impending death (Poor, 2001, p.6). The tools are assessment measures of the conditions of the patients and the acceptance of the patients for the concept of death (Poor, 2001, p.6). As for the quality of end-of-life care, it remains a sensitive issue, as it intersects other issues, such as euthanasia, especially when patients and kin, or patients and doctors, diverge on when it is time to stop treatment. The tools for measuring the quality of end-of-life care remains troublesome among health care providers. Epstein (2010) complains that nurses and physicians fail to coordinate their efforts to provide holistic care along the “illness trajectory,” because of “silos” that segregate the two professions (p.578). Nevertheless, quality of end-of-life care focuses on the first step of acceptance of death. Measurements for quality of end-of-life care can be based on the discussed criteria of the concept. These criteria are already based on the characteristics of good palliative care defined by the WHO. Antecedents and Consequences Antecedents The antecedents of end of life are the shortness of expectation of survivability and the patient’s recognition of the reality of death (Poor, 2001, p.6). The antecedents of end of life care are the imminence of death, the desire to simply wait for death to occur, the openness to preparing advance care plans, and the collaboration among stakeholders, including between health care providers and patients and kin, as well as among the health care staff or that between nurses and doctors (Lippincott Williams and Wilkins, 2007, p.3). Consequences The consequences of end of life are the withdrawal of extension-of-life measures and the focus on actions that will make end of life more comfortable or manageable (Lippincott Williams and Wilkins, 2007, p.3). Without the concept of end of care, the health care staff would not be able to launch the differences between this stage and the curative stage. In the absence of end-of-life care, it is possible that patients will not receive holistic quality care, because palliative care seeks to respond to the psychological, spiritual, and practical needs and issues of patients (Lippincott Williams and Wilkins, 2007, p.3). For instance, those who are mentally incapacitated and have not created plans for their end of life care may receive either unnecessary expensive medical interventions or the pulling out of desired symptom-alleviation procedures or medicines (Lambert et al. 2005 as cited in Jeong, Higgins, & McMillan, 2010, p.390). It is also possible for the patients and their families to suffer from depression and further health problems, because of lack of responsiveness to the patients’ palliative care needs (Wills, 2001, pp.21-22). Studies have noted that there is a co-variation between relatives’ intensity of anxiety and patient’s physical and mental symptoms, where having less responsiveness to the patient’s symptoms can increase the family members’ anxiety (Karlsson & Berggren, 2011, p.375). Furthermore, co-variation also occurs between the families’ level of anxiety and their communication with the patient, where poor communication also enhances the family’s anxiety level (Karlsson & Berggren, 2011, p.375). Three Cases Model Case The model case is when a patient receives all of the criteria in good end-of-life care. Mrs. Luisa, a patient with dementia, decided to stop receiving treatment. She and her relatives already acknowledged that she will die soon. Second, the doctors and nurses have consulted the patient and kin for an advance end-of-life care plan, where the symptoms’ relief is outlined. The plan also integrates psychological, social, practical, and spiritual aspects of patient care in planning for end-of-life care. Luisa just wants to receive drugs that relieve her pain, but for any other terminal symptoms, she prefers to just allow the natural course of death to take place. As a Muslim, she already integrates her spiritual beliefs into her care. She prefers to die at home and be taken care of her relatives and a hired nurse. Third, the plan includes providing a support system to help the family cope during the patient’s illness and their own bereavement (WHO as cited in Poor, 2001, p.6). The family receives counseling and is prepared for their parent’s imminent death. Finally, there should be a clear system of transparency and accountability in the decision-making process (Gjerberg, Førde, & Bjørndal, 2011, p.43). The relatives understand that they would no longer interfere, in case there will be new symptoms that can lead to their patient’s death. Contrary Case An example of contrary case is when the patient is not ready to die like the wife of a famous attorney. The wife is diagnosed with breast cancer but rejects chemotherapy and other drugs. She believes that she will heal on her own, when she gets her strength back. As a result, the health care staff focuses on keeping her comfortable with her pain. The patient dies, without her family being prepared for her demise. They are deeply affected by this loss. Invented Case A sixty-year old man has decided to stop treatment for lung cancer and just wait for his death. The patient already received chemotherapy, but his conditions continued to worsen. His kidneys are failing too. The patient, relatives, and health care staff have acknowledged the imminence of death. Specifically, the patient and his/her relatives understand that they will no longer prolong life and they will only wait for their patient’s natural course of death. Second, the doctors and nurses have consulted the patient and kin for the advance end-of-life care plan, where the symptoms’ relief is outlined. The plan also integrates psychological, social, practical, and spiritual aspects of patient care in planning for end-of-life care. Since the patient is Catholic, he already listens to Bible readings every day and receives visits from a priest. Third, the plan includes providing a support system to help the family cope during the patient’s illness and their own bereavement (WHO as cited in Poor, 2001, p.6). This includes counseling for the family and preparing them for the patient’s death. Finally, there should be a clear system of transparency and accountability in the decision-making process (Gjerberg, Førde, & Bjørndal, 2011, p.43). If the patient signs a do-not-resuscitate order, the relatives should respect this decision, no matter how hard it is for them to let go. References Epstein, E. G. (2010). Moral obligations of nurses and physicians in neonatal end-of-life care. Nursing Ethics, 17 (5), 577-589. Gjerberg, E., Førde, R., & Bjørndal, A. (2011, January 1). Staff and family relationships in end-of-life nursing home care. Nursing Ethics, 18 (1), 42-53. Jeong, S. Y., Higgins, I., & McMillan, M. (2010). The essentials of Advance Care Planning for end-of-life care for older people. Journal of Clinical Nursing, 19 (3/4), 389-397. Karlsson, C. & Berggren, I. (2011, May 1). Dignified end-of-life care in the patients' own homes. Nursing Ethics, 18 (3), 374-385. Lippincott Williams & Wilkins. (2007). End-of-life: a nurse's guide to compassionate care. Philadelphia : Lippincott Williams & Wilkins. Poor, B. (2001). Palliative care and quality of life in caring for the dying. In B. Poor and G.P. Poirrier (Eds.), End of life nursing care (pp.3-12). London: Jones & Bartlett Publishers. Reinke, L.F., Shannon, S.E., Engelberg, R., Dotolo, D., Silvestri, G.A., & Curtis, J. R. (2010). Nurses' identification of important yet under-utilized end-of-life care skills for patients with life-limiting or terminal illnesses. Journal of Palliative Medicine, 13 (6), 753-759. Wills, E.M. (2001). Holistic models. In B. Poor and G.P. Poirrier (Eds.), End of life nursing care (pp.19-28). London: Jones & Bartlett Publishers. Read More